The Integrated Community Ageing Team (ICAT) team is part of the care group delivering proactive care in Islington and known as Frailty and Complex Care Team (FACCT). ICAT specialises in the assessment and management of frail older people.

The consultant-led, multidisciplinary team (MDT) includes:

• consultant geriatrician input from University College London Hospitals and Whittington Health
• a GP with specialist interest in geriatrics
• a GP registrar on a rotational basis
• an FY2 doctor on a rotational basis
• two nurses specialising in older people
• two pharmacists
• a pharmacy technician
• an occupational therapist specialising in older people
• two physiotherapists specialising in older people
• a therapy assistant
• a patient pathway co-ordinator
• access to a social worker within the care group.

The team works collaboratively with primary care to carry out a comprehensive geriatric assessment (CGA) and to create a care plan that addresses the person's needs, usually in a person's own home. 

If diagnostics are needed, ICAT is able to arrange for the appropriate tests to be carried out at Whittington Hospital. Twice weekly multidisciplinary team meetings take place, and all input is documented directly onto EMIS (accessible to GP's by clicking View All Records within consultations). 

Please note: ICAT is not a rapid response service. ICAT aims to carry out first assessments within two weeks of referral, but at busy times waiting times may increase. If you are worried about a patient waiting this long, call the ICAT consultant hotline for advice. 

ICAT care home work

ICAT also provides support and in-reach into the care homes in Islington. Each care home and associated GP practice work in collaboration with a consultant geriatrician, pharmacist and pharmacy technician, who attend monthly MDTs at the care home and will see patients at the home.

Eligibility Criteria

Inclusions

The patient should be in need of a CGA:

• patients aged 75+ will be triaged
• for patients aged 70-75 years, the referral needs to be discussed with an ICAT doctor via the hotline.

Frailty is a complex syndrome to define, but commonly presents as one of the following:  

• increasing immobility
• falls
• general functional decline
• worsening confusion
• polypharmacy and issues with medications management
• multiple deteriorating long-term conditions
• recurrent hospital admissions or new incontinence.

A person with any of these problems is likely to benefit from a CGA.

Exclusions

• patients who do not have an Islington GP
• patients aged < 70 
• patients who only need therapy or pharmacy input (consider REACH for therapy and practice based pharmacy; the service also offers a therapy-led falls service with pharmacy input). 

How to Refer